We refer to Mr S. Ratnakumar's letter, which implied that palliative care, by withholding feeding tubes and medication, caused death by starvation or dehydration (Healthy to discuss euthanasia openly; Aug 18).

These assertions stem from a lack of understanding of the dying process and the guiding philosophy of palliative care.

Natural death occurs in several ways, for instance, through cancer, end-stage organ failure or degenerative illnesses.

These varied causes converge into a final common dying process. Death is not a single event but a series of events.

One of the hallmarks of the dying process is when the patient loses interest in food and starts losing weight.

The body is adapting to the less active person's diminished need for calories and energy.

As the functions of the various organs start to wind down, the dying person begins to "rest" and sleep more.

Meanwhile, his nutritional and fluid needs continue to decline as the cells die off and his organs fail.

Even the digestive system is not spared this gradual shutdown.

At this juncture, forcing food and fluids will not have any bearing on life and may even lead to distress, such as swelling, excessive secretions, breathlessness and vomiting.

Death occurs when the heart stops beating and the brain, cut off from its blood supply, finally switches off.

Death comes not from palliative care but from the terminal illness itself.

The goal of palliative care is not to cause death, but to care for the dying patient and family as they take that final journey.

It seeks neither to hasten death nor prolong the dying process through unnatural or burdensome means. It attempts to take the sting out of death.

James Low (A/Prof)

Co-Chairman

Ethics Advisory Committee

Singapore Hospice Council